Lee Memorial Health System Board of Directors … · Board of Directors of its subsidiary corporations, ... BoardCompass® Board Self-Assessment Results Presentation. 2 ... organization’s

Lee Memorial Health System Board of Directors

Education Workshop Tuesday, January 20, 2015

12:30 p.m. – 2:00 p.m.

BOARD OF DIRECTORS

OFFICE 239-343-1500

FAX: 239-343-1599

13685 DOCTORS WAY #190 FT MYERS, FLORIDA 33912

CAPE CORAL HOSPITAL

GULF COAST MEDICAL CENTER

HEALTHPARK MEDICAL CENTER

LEE MEMORIAL HOSPITAL

GOLISANO’S CHILDRENS HOSPITAL OF SOUTHWEST FLORIDA

THE REHABILITATION HOSPITAL

LEE PHYSICIAN GROUP

LEE CONVENIENT CARE

BOARD OF DIRECTORS

DISTRICT ONE

Stephen R. Brown, M.D.

Therese Everly

DISTRICT TWO

Donna Clarke

Nancy M. McGovern, RN, MSM

DISTRICT THREE

Sanford N. Cohen, M.D.

David Collins

DISTRICT FOUR

Diane Champion

Chris Hansen

DISTRICT FIVE

Jessica Carter

Stephanie Meyer, BSN, RN

AGENDA

BOARD OF DIRECTORS

EDUCATIONAL WORKSHOP

January 20, 2015 1:00 p.m.

The Ritz-Carlton 280 Vanderbilt Beach Road, Naples FL 34108

012015 BOARDWORKSOP\AGENDA(FINAL).doc Page 1 of 1

1. CALL TO ORDER (Sanford Cohen, M.D., Board Chairman) Lee Memorial Health System Board of Directors, sitting as the Lee Memorial Health System (LMHS) Board of Directors for Gulf Coast Medical Center & Lee Memorial Hospital/HealthPark Medical Center and the Board of Directors of its subsidiary corporations, including but not limited to Cape Memorial Hospital, Inc. doing business as Cape Coral Hospital; Lee Memorial Home Health, Inc.; and HealthPark Care Center, Inc.

2. THE GOVERNANCE INSTITUTE – BOARD SELF-ASSESSMENT RESULTS (Ritika Golej- Account Manager)

A. Overview of Lee Memorial Health System Board Self-Assessment Results B. Governance Development Plan C. How The Governance Institute can Best Support Lee Memorial Health

System

14. Date of the next Meeting:

Thursday, January 29, 2015: 1:00pm Finance Board & Full Board of Directors Gulf Coast Medical Center – Boardroom

13685 Doctors Way, Ft. Myers, FL 33912

15. ADJOURN (Sanford Cohen, M.D., Board Chairman)

The Governance Institute

BoardCompass® Board Self-Assessment

Results Presentation

2

• Mission

– To provide trusted, independent information to board members, physician

leaders and healthcare executives to help them better lead and govern

their organizations

• Non-Profit Healthcare Organizations

– 1064 members as of July 2013


32%

16%

44%

8%

Member Breakdown

Systems

Subsidiary

Community

Critical Access

3


Assessments

Research and

Publications

Board Education

Portal

National and Regional

Conferences

• Board Self-Assessment

• Readiness Assessment

• Foundation Board Assessment

• National Benchmarking

• Trusted, 3rd- party,

member-driven content

• Case studies

• Largest study on

Governance Structures

and Practices

• National Expertise

• Didactic & Interactive

• Networking for trustees,

physician leaders,

executives, and

governance support staff

Tools and Resources

• TGI information distributed through

portal

• SAS 70 Type II certified network servers

• #1 board portal in the healthcare

industry

Assessments

Research and

Publications

Board Education

Portal

National and Regional

Conferences

• Board Self-Assessment

• Readiness Assessment

• Foundation Board Assessment

• National Benchmarking

• National Expertise

• Didactic & Interactive

• Networking for trustees,

physician leaders,

executives, and

governance support staff

• TGI information distributed through

portal

• SAS 70 Type II certified network servers

• #1 board portal in the healthcare

industry

4

Job Description

“Keeper of Governance Integrity”

Leadership

Role Clarification

Liaison

Meetings

Board Conduct

Education

CEO Evaluation

Self-Evaluation

5

GovernanceInstitute.com

Session Objectives

5

• Review and Discuss– Overview of the Lee Memorial Health System Board Self-Assessment Results

• Governance Development Plan – Strategies and Recommended Practices for Improvement

• Overview of Governance Institute Resources– Discussion of How The Governance Institute can Best Support the Ongoing

Efforts of Lee Memorial Health System

6

Lee Memorial Health System

Board Self-Assessment

7

Introduction

8

Features of the Assessment

• Board members are asked, “On a scale of 1-10, with 10 being high, please rate the effectiveness of the board.”

• In the results, average top box scores are provided for each category.

Overall Board Effectiveness Ratings

• If there was one improvement the board could make to be more effective in the upcoming year, what would that change be?

• What suggestions do you have for ongoing education topics?

Open-Ended Questions

• Provides data of what the board rates as its performance at the highest level possible.

Top-Box Ratings

8

9


Effectiveness Rating

Effectiveness Rating: On a scale of 1–10, Lee Memorial Health System’s board rated the effectiveness of the board overall:

Response Rate: 8 out of 9 board members responded to Lee Memorial Health

System’s board self-assessment, resulting in a response rate of 89%.

8.1

7.6

0 2 4 6 8 10

Overall Score

Lee Memorial HealthSystem

National Benchmark

10

Overall RatingsOverall Ratings are calculated

by combining the overall “top-

box” ratings for each category.

Those responses are then

compared to The Governance

Institute’s national database of

organizations that completed

the board self-assessment.

Top-Box RatingsTop-Box ratings reflect what

percentage of your board rated

its performance at the highest

level possible, or the top-most

rating.

Overall Ratings

11

Strategic Governance

12

Strategic Governance: Strategic Planning

Requiring that major strategic initiatives specify measurable

criteria for success and individual accountabilities

63% 13% 25%

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

13


Setting annual goals for board performance that support the

organization’s strategic direction/plan

13% 25% 38% 25%

Very Effective

Effective

Neutral

Ineffective

Very Ineffective

14


Best Practices for Increasing the Board’s Role in Direction Setting & Planning

Three foundational board

practices to lead strategic

direction efforts within the

organization:

1. Educated Board Members

2. Active Board Involvement

3. Stakeholder Engagement

Board Involvement in Strategic Planning

15

Strategic Governance: Strategic Discussion

Spending more than half of most board meetings discussing

strategic issues as opposed to hearing reports

25% 13% 50% 13%

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

16

Strategic Governance: Strategic Discussion

Strategic Issues: Determine what your organization should achieve, undertake,

pursue a goal and/or initiative.

Operational Issues: Determine how your organization should achieve,

undertake, and/or pursue a goal and/or initiative.

• Hold each other accountable for staying informed and engaged

• Prioritize discussion over reporting (e.g. assume all have read the board packet and set

the expectation that there will be no verbal reports of materials that were provided

before the meeting)

• Develop a board calendar based on the strategic plan with a specific strategic topic

identified for each board meeting

17

Strategic Governance: Mission Statement & Fiduciary Duty of Obedience

Reviewing the hospital’s mission statement annually to ensure its

ongoing appropriateness

25% 38% 25% 13%

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

18


Considering whether a major decision will impact the

organization’s mission before approving it

13% 50% 13% 25%

Very Effective

Effective

Neutral

Ineffective

Very Ineffective

19


Duty of Obedience: Ensure that the organization’s decisions and activities adhere to the fundamental

purpose and the mission of the organization.

What does this

mission statement

mean to you?

Lee Memorial Mission Statement:

To continue to meet the health

care needs and improve the

health status of the people of

Southwest Florida.

20

Strategic Governance: Open-Ended Responses

“Spending more than half of most board meetings discussing strategic issues as opposed to hearing reports”

“Requiring that major strategic initiatives specify measurable criteria for success and individual”

“More strategic discussion”

If there was one improvement the

board could make to be more

effective in the upcoming year,

what would that change be?

What suggestions do you have for

ongoing board education topics?

“Strategic dialogue & learning to ask

more meaningful questions of staff.

Strategic Planning!!”

21


Recommendations:

• Strategic Planning Education on the board’s role in planning & oversight

Clear communication on ongoing initiatives from the strategic plan

• Strategic Discussion Effective Board Meetings

Ongoing Education to Help Frame Board Member Discussion

• Mission Statement & Fiduciary Duty of Obedience Chairman’s Report focused on the board’s duty of obedience to the mission

Present strategic initiatives and how the tie into the mission of the organization

*Helpful Resources: Elements of Governance® Effective Board Meeting, Elements of Governance® Strategic Planning and Direction Setting, board portal, Leadership Conferences, publications and content, sample agendas

22


Effective Board Meetings• Materials in advance

• Timed & labelled agendas

• Strong chair leadership

• Post-meeting evaluation

23


Strategic Retreats

Conferences:

• National perspective on the changes & challenges facing the

industry

• Opportunity to network with peers

*Conducting an Educational Retreat onsite at a conference can

allow the board to unpack what they are learning and directly

apply it to Lee Memorial Health System.

The Governance Institute’s education programs are

designed to support innovative leadership

24


Ongoing Education & Development• Quarterly White Papers

• Bi-monthly BoardRoom Press newsletters

• Online e-Briefings newsletter

• Orientation Resources

• DVDs programs

• Webinars

• E-Learning Courses

• Research

• Member Editorial Board

• Elements of Governance, healthcare fundamentals


25

CEO Succession Planning

26



Requiring the CEO to have a written and current succession plan

13% 38% 13% 25% 13%

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

27



Boards engaged in thorough leadership transition planning are:• Focused on the future and the role a new

CEO will play in leading the organization forward

• Proactive and intentional about management development and building executive competencies

• Focused on ensuring an effective, smooth transition

• Determined to maintain high performance through the transition period

28



Recommendations:

• Review, Update, and Implement a CEO

Succession Plan, elements to include: Timetable

Search and Selection Process

Transition Plan

Retention Planning

CEO Employment Agreement

Communication Plan

*Helpful Resources: Elements of Governance® Succession

Planning, 2nd edition

29

Educational Opportunities

30


Educational Opportunities: Policies

Enforcing a written policy on confidentiality

13% 50% 38%

Very Effective

Effective

Neutral

Ineffective

Very Ineffective

31



Having written policy(ies) outlining the approach to competition

and conflict of interest for the organization’s physicians

50% 25% 25%

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

32



Reviewing all sentinel events and root cause analyses promptly

38% 25% 25% 13%

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

33



Having a board policy establishing the board member’s role in

fund development and/or philanthropy

13% 25% 63%

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

34



Recommendation:

• Education for the board on the following policies: Confidentiality Policy

Physician Competition and Conflict-of-Interest Policy

Fund Development/Philanthropy Policy

Sentinel Event Review Process

• Ensure access to policies for future reference

• Education for the board re: policy review process every three years

*Helpful Resources: Board Portal

35


Educational Opportunities: Board Leadership Succession Planning

Having a formalized board leadership succession plan to develop

and select officers

13% 13% 38% 38%

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

36


Educational Opportunities: Board Leadership Succession Planning

Recommendation:

• Education for the board on Lee Memorial’s

Health System’s process for appointing

future board leaders, includingClear process for selecting officers

List of competencies and prerequisites for officers

*Helpful Resources: Elements of Governance®

Planning for Future Board Leadership

37


Educational Opportunities: Physician Leadership

Ensuring appropriate physician involvement in governance

25% 25% 13% 13% 25%

Very Effective

Effective

Neutral

Ineffective

Very Ineffective

38


Educational Opportunities: Physician Leadership

Recommendation:

• Education session on physician leadership, to

include: Educational resources provided by The Governance

Institute

Discussion on the role of physician leaders in governance

at Lee Memorial Health System

*Helpful Resources: BoardRoom Press® Special Section “The Board’s Role in Physician

Leadership Development” by Elaine Zablocki, BoardRoom Press® article “Beyond Governance

to True Physician Leadership Engagement” by Chris Van Gorder

39


Educational Opportunities: Physician Credentialing

Setting criteria, independent of the medical executive committee,

to guide medical staff recommendations for physician

appointments, reappointments, and clinical privileges

13% 38% 13% 38%

Very Effective

Effective

Neutral

Ineffective

Very Ineffective

40



“One of the strongest

mechanisms for ensuring

quality is rigorous

credentialing of the

practitioners who will

provide care in the

institution”-Todd Sagin, M.D., J.D.

41



Recommendation:

• Define and conduct education on the role

of the board in the credentialing process

*Helpful Resources: Elements of Governance® Physician Credentialing: An

Orientation Manual for Board Members

42

Final Summary and Takeaways

43


Governance Development Plan

44


The Governance Institute Resources

Intentional Alignment Board Recruitment & Retention

Orientation – Board Basics

Graduate Level Governance

Extensive Governance Research

Peer-to-Peer Access

Best Practice Recommendations

Governance Support Resources

Execution & Access Board Meeting Books

Committee Workspace

Synchronized Calendar

Polling & Surveying

Ongoing Communication

Secure Storage Space

National Exposure Current Healthcare Knowledge

Interaction

Expert Speakers

Evaluation & Improvement Largest Comparative Database

Custom Development Plan – Create Goals

Fiduciary Board

Advisory Board

Foundation Board

Committee Evaluations

45


Ritika Golej

Account Manager


(877) 712-8778

[email protected]

Thank you!

mailto:[email protected]

Documents

Lee Memorial Health System Board of Directors … · Board of Directors of its subsidiary corporations, ... BoardCompass® Board Self-Assessment Results Presentation. 2 ... organization’s